An injury to his right knee, a concussion and a sports hernia derailed the season for Texans rookie Jadeveon Clowney, the top pick.
Microfracture surgery isn't for everyone.
The question is, was it the best option for someone in Jadeveon Clowney's demographic, which is to say a young, strong, fit and - hopefully - highly motivated elite athlete?
Clearly, the Texans, their orthopedist Dr. Walt Lowe, and Dr. James Andrews, to whom they went for a second opinion, believed the operation was the right way to go. Texans rookie linebacker Clowney, 21, underwent the surgery, performed by Lowe, on Monday
But there are strong dissenting opinions. Dr. Richard Lehman, a prominent orthopedic surgeon and founder of the U.S. Center for Sports Medicine in St. Louis, believes microfracture "is fine for weekend warriors, but I'm not a fan of it for an elite athlete like Jadeveon Clowney."
In Clowney's case, Lehman said, "It could be career-ending. Everybody knows that."
Lehman is a proponent of an alternative procedure, articular cartilage reconstruction, which he pioneered. It involves growing cartilage outside the body, then inserting it to replace what has been damaged.
"I think it's a better way to go," Lehman said, "than using cartilage that's essentially scar tissue."
Microfracture is a relatively simple, painless procedure, usually requiring less than 45 minutes. But the recovery period is long and arduous - perhaps even more so mentally than physically. Clowney (6-5, 266 pounds) faces weeks of forced inactivity, then months of grueling physical therapy before he'll find out if he can become the player everyone expected when the Texans selected him with the first pick in the 2014 draft.
"It's the most common procedure for (articular) cartilage repair done in the world today," said Dr. Bert Mandelbaum, an orthopedic surgeon and co-chair of medical affairs at the Institute for Sports Sciences in Los Angeles. He has been performing microfracture operations for two decades, having followed in the footsteps of the procedure's pioneer, Dr. Richard Steadman, of Vail, Colo.
He has performed microfracture operations for two decades, following in the footsteps of the physician who developed it, Dr. Richard Steadman of Vail, Colo.
The surgery entails drilling tiny holes - "fractures" - in the lower leg bone plate, allowing blood and bone marrow to seep out, forming a blood clot that releases cartilage-building stem cells from the marrow.
But Mandelbaum said, "The challenge of getting the cartilage to regenerate can be a tough one" - it increases exponentially the bigger the gouge, or divot, in the membrane happens to be - and the effectiveness varies from patient to patient, probably based on stem cell population.
Mandelbaum said about two-thirds of all microfracture operations are successful. He couldn't speak to the issues Clowney might deal with in his damaged right knee, making it impossible for him to offer a prognosis, and Lowe hasn't been available for comment.
But Mandelbaum believes Clowney "is in good hands." He knows Lowe and holds him in high esteem.
Injured in opener
Lowe performed arthroscopic surgery on Clowney's knee Sept. 9 to repair a torn lateral meniscus cartilage, suffered two days earlier in the season opener against Washington on a late first-half play on which he landed awkwardly.
It was hoped that repairing the meniscus would suffice, but Lowe apparently also found damage to the articular cartilage, the delicate membrane that coats the tips of the bones, serving as a shock absorber and preventing them from pounding and grinding together, which causes more damage and can lead to excruciating pain.
Replays show Clowney had rushed quarterback Robert Griffin III, making a sharp zigzag cut en route, but he arrived a split second after Griffin had been knocked down by J.J. Watt close to the Washington goal line.
Clowney leaped, seemingly trying to avoid stepping on Watt, and he came down hard on his right foot. On his next step, he was limping, and he didn't return to the game.
Gave it a shot
Clowney played seven weeks later against Tennessee but seemed to be unsure of himself and favoring his right knee. He took another two weeks off around the Texans' open date before taking the field again in Cleveland and against Cincinnati at home. In the latter game, he participated in a season-high 49 snaps, but he experienced significant swelling afterward, prompting the Texans to send him to be examined by Andrews at his clinic in Pensacola, Fla.
One thing working against Clowney is his size. The regenerated cartilage, called fibrocartilage, isn't as durable as the natural, or hyaline, cartilage.
It appears the chances are relatively high he'll have to undergo another microfracture surgery a couple of seasons down the road.
"A lot of people's results have not been very good with it," said Dr. Gary Brock, a pediatric orthopedist in Houston. "He's going to have a tough road coming back unless it's a very small lesion."
Two athletes who recovered successfully from microfracture surgery, Lions running back Reggie Bush and former Utah Jazz point guard John Stockton, are small guys. Hall of Fame defensive end Bruce Smith, definitely a big guy, also prospered afterward.
But a large body who couldn't come back from it was former Texans offensive lineman Chester Pitts.
Pitts, an original Texan, was in the team's locker room Wednesday. He spoke at length about his ordeal, but his intent was to debunk the notion microfracture surgery forced him to retire following the 2010 season.
He was hurt two games into the 2009 season, ending his streak of 114 consecutive starts for the Texans, who released him at the end of the year.
Pitts played most of the following season for the Seattle Seahawks but admits the knee never felt right.
"I blame the injury, not the surgery - I just had too much damage in there," he said, noting the bones in the joint had been essentially pulverized at their tips. "If it's a small area (of damage), it can work fine. Mine was about the size of a silver dollar. But I think the operation was the only thing that was going to give me any chance to keep playing."
Pitts is more optimistic about Clowney's prospects for a full recovery because the prized rookie didn't suffer a trauma-causing blow to the knee, as happened to him.
Russ Paine of the Memorial-Hermann Sports Medicine Institute, regarded as one of Houston's top physical therapists, has had no personal interaction with Clowney, but he has considerable experience working with microfracture surgery patients. He believes the key to Clowney's recovery hinges hugely upon his work ethic, specifically his willingness to strengthen the leg.
Leg strength key
"The stronger the muscles are on both sides of the knee," Paine said, "the better they can help to act as shock absorbers."
Paine added that stationary cycling also figures to be a significant component of Clowney's rehab.
"Motion is extremely good for the articular cartilage," he said. "It's like squeezing a sponge. It gets the synovial fluid flowing through the knee joint."
Clowney's teammate Brian Cushing knows more about recovering from knee surgery than any Texan, having undergone major operations in each of the last two seasons. The microfracture process couldn't have helped Cushing recover from the torn anterior cruciate and medial collateral ligaments he suffered, but he is well-versed in what's ahead for Clowney.
"It's extremely hard," Cushing said, "especially in the offseason when nobody's here. It's more mental than anything, knowing how many more days and hours you have to put in with very monotonous workouts, with routines that aren't very fun. There will also be a lot of pain involved. But you need to remember that every day you go through it, you're one step closer to getting back."
Safety D.J. Swearinger was Clowney's teammate at South Carolina and has the best point of reference of any Texan. Swearinger watched Clowney with increasing alarm as he tried to play following his meniscus repair, realizing he was hardly seeing the same player he remembered. Clowney confirmed in private conversations that something was wrong with his knee.
"It was a crazy situation," Swearinger said. "That's tough luck to have to go through it at the start of your career. He needs to stay prayed up and do what he has to do to get the knee back right and get back on the field in the near future. He's got to work hard and stay positive about everything."